The early prediction of mortality in acute cholecystitis: Temperature, Neutrophils and Multiple organ failure (TNM) score.

OBJECTIVE: Acute Cholecystitis (AC) accounts for a significant proportion of patients presenting to the Emergency Department with abdominal pain. We suggest grading the severity of AC with a simple system: TNM, an acronym borrowed by cancer staging where T indicated Temperature, N neutrophils and M Multiple organ failure. This retrospective-prospective observational study evaluates the predictive value of TNM score on mortality of patients with AC. PATIENTS AND METHODS: TNM was developed in a training cohort of 178 patients with AC who underwent cholecystectomy from February 2005 to December 2012 (retrospectives data). To verify the prognostic value of TNM score, we prospectively recruited 172 patients who were consecutively included and treated from January 2013 to July 2020 as the validation cohort. After defining the categories T, N and M, patients were grouped in stages. The variables analyzed were age, sex, American Society of Anesthesiologists (ASA) score, blood transfusion, temperature, neutrophils count, preoperative organ failure, immune-compromised status, stage. RESULTS: In the training cohort TNM staging was: none patient at stage 0; 6 patients at stage I; 71 patients at stage II; 71 patients at stage III; 30 patients at stage IV. Death occurred in 51 patients. ASA score, neutrophils count, preoperative organ failure, stage III-IV emerged as statistically significant different prognostic factors. ASA score (III-IV) and stage (III-IV) were significant independent predictors of post-operative mortality in multivariate analysis. Comparable results were observed in the validation cohort. CONCLUSIONS: TNM classification is very easy to use; it helps to define the mortality risk and it is useful to objectively compare patients with AC.

COVID-19 lockdown impact on common general surgical acute presentations to a regional centre in New Zealand.

AIM: New Zealand's stated goal of eradicating COVID-19 included the enforcement of a national lockdown. During this time, a perceived decrease in hospital presentations nationwide was noted. This was also the experience of the Department of General Surgery, Bay of Plenty District Health Board (BOPDHB). We sought to quantify this reduction by analysing the frequency and severity of three common acute general surgical presentations; appendicitis, cholecystitis and diverticulitis. METHODS: Data on presentations of patients with appendicitis, cholecystitis and diverticulitis were retrospectively collected for the national lockdown period (25 March 2020-27 April 2020) and the immediate pre-lockdown period (21 February 2020-25 March 2020). Data collected included patient demographics, duration of symptoms, method of diagnosis, treatment, severity of disease, length of stay and complications. RESULTS: A reduction of 62.2% was noted in the frequency of appendicitis during the lockdown period compared to the pre-lockdown period. Patients presented later during lockdown and had a higher complication rate (5.4% versus 42.8%). Similarly, a 39.2% reduction in presentations of cholecystitis during lockdown was found. The lockdown group of patients had a longer length of stay (6.9 versus 4 days) and only one patient (9.1%, 1/11) was managed with laparoscopic cholecystectomy during the lockdown period, compared to 52.9% of patients (9/17) over the pre-lockdown period. No difference in frequency or severity of acute diverticulitis presentations between the two periods was found. CONCLUSIONS: The COVID-19 lockdown led to fewer presentations, but these were often delayed, with more complications and a longer length of stay. This could be partly explained by patient fear around exposure to the virus and reluctance to attend hospital. More research is needed to study the flow-on effects of the COVID-19 lockdown on surgical presentations.

Surgical treatment of acute cholecystitis in obese patients.

<b>Introduction:</b> In today's technological climate, science and medicine have entered a new era. At the level of technological progress, we have identified millennia of "new" problems and diseases. If earlier diseases had a certain individuality then, in the third millennium, we face compliance and synergistic influence of diseases. Obesity is a problem of the third millennium. It is known that obesity is the main factor in the development of various chronic diseases [1-3]. With excess weight and obesity, bile is oversaturated with cholesterol, resulting in an increase of its lipogenicity index. As a result, frequency of gallstone disease increases; findings from this study document an increase of disease frequency as high as 50% to 60% [4]. In 20% of patients, housing concerns are combined with obesity [5]. Thus, obesity is one of the factors in the development of cholelithiasis and cholecystitis [6]. The presence of acute cholecystitis represents the most difficult situation for patients with gallstones. When obesity is also present, the patient's risk of surgical complications increases due to altered homeostasis and reduced reserve capacity [7]. A retrospective study of this issue [8] posed a number of questions about the possibility of influencing the course of disease in the preoperative period as well as the improvement and impact of surgical technicalities in patients with acute cholecystitis and obesity. Addressing these and additional questions is the main goal of this study. <br><b>Aim: </b>The aim of the study was to study and select the optimal method of surgery in patients with acute cholecystitis and obesity. <br><b>Materials and methods:</b> In our study, a prospective analysis was used. We analyzed 67 cases with diagnosis of acute cholecystitis and obesity; all were treated at Kyiv Regional Clinical Hospital in the period from September 2018 to March 2020. Patients with acute cholecystitis and obesity received either traditional or modified laparoscopic cholecystectomy. <br><b>Results:</b> Retrospective analysis indicates traditional laparoscopic cholecystectomy is technically difficult and costly in patients with acute cholecystitis and obesity. A modified laparoscopic cholecystectomy has been proposed to improve and enhance surgery in patients with acute cholecystitis and obesity. Surgical duration was shortened by 9.01 ± 0.41 minutes (p = 0.001; αα= 0.05) when a modified laparoscopic cholecystectomy was performed. <br><b>Conclusions:</b> Performing a modified laparoscopic cholecystectomy reduced the duration of surgery by 9.01 ± 0.41 minutes (p = 0.001; α = 0.05), prevents development of metabolic acidosis pH 7.39 ± 0.03 vs 7.30 ± 0.005 = 0.001; αα= 0.05, pCO2 5.05 ± 0.36 vs 6.03 ± 0.38 (p = 0.02; αα= 0.05), reducing the risk of hypercoagulation. Modified laparoscopic cholecystectomy (LHE) is effective in II and III degrees of obesity (p = 0.001; α = 0.05).

Percutaneous cholecystostomy for severe (Tokyo 2013 stage III) acute cholecystitis.

PURPOSES: To evaluate the impact of percutaneous cholecystostomy (PC) on severe acute cholecystitis (AC). METHODS: According to the ICD-9 classification, we retrospectively retrieved medical records of patients discharged with a diagnosis of AC from January 2007 to December 2016 at our hospital. Patients were then stratified according to the Tokyo 2013 (TG 13) AC severity criteria. Grade III AC was diagnosed according to the TG 13 criteria. Indications for PC were failure of optimal medical treatment within 48 h, worsening of clinical condition within early medical treatment, patients unfit for upfront surgery and patient's preference. Ascites was considered a contraindication to PC while coagulopathy was considered a minor contraindication. Primary end points were: clinical improvement, morbidity and related mortality. Secondary endpoints were AC recurrences and elective laparoscopic cholecystectomies (LS). Response was evaluated by clinical and blood test improvement. Morbidity was evaluated according to the Dindo-Clavien scale. RESULTS: A total of 117 eligible patients were diagnosed as grade III AC. Of these, 29 (24.7%) underwent PC. The procedure was completed in all cases. Overall morbidity rate was 20.6%. Main complication was the drainage dislodgement due to involuntary patient's movement. Overall mortality was 17.2% but no causes of death were dependent upon the procedure. Clinical improvement was reported in 95.5% of surviving patients. CONCLUSION: This study confirms that PC is a valuable tool in the treatment of severe AC. Randomized trials are needed to clarify the criteria for patient selection and to optimize the timing for both cholecystostomy and cholecystectomy.

Neutrophils injure gallbladder interstitial Cajal-like cells in a guinea pig model of acute cholecystitis.

Acute cholecystitis is a common disease with gallbladder dysmotility. Disease pathogenesis involves immune cell infiltration as well as changes in gallbladder interstitial Cajal-like cells (ICLCs). However, it remains unclear if or how the immune cells affect ICLC morphology, density, distribution, and function in gallbladder tissue during acute cholecystitis. In this study, we explored the acute cholecystitis-related alterations in gallbladder ICLCs in a guinea pig model, focusing on the effects of neighboring neutrophils. Adult guinea pigs were randomly divided into four groups (control, 24 hr common bile duct ligation [CBDL], 48-hr CBDL, and antipolymorphonuclear neutrophil [PMN] treated) and analyzed using methylene blue staining and immunofluorescence. Gallbladder contractility was also monitored. To culture gallbladder ICLCs, collagenase digestion was performed on tissue from 10- to 15-day-old guinea pigs. Neutrophils isolated from the peripheral blood of experimental animals 48-hr postsurgery were also cocultured with the gallbladder ICLCs. Intracellular calcium was detected with Fluo-4 AM dye. Our results showed that gallbladder ICLC density significantly declined during acute cholecystitis and was accompanied by shortening of the cellular processes and damage to their network-like structure. However, pretreatment with anti-PMN partially prevented these changes. Gallbladder contraction was also significantly decreased during acute cholecystitis, and this appeared to be mediated by the neutrophils. Moreover, ICLCs cocultured with neutrophils also had shortened and reduced processes and impaired network-like structure formation. Intracellular calcium transient was less sensitive to contraction agonists and inhibitors when cocultured with neutrophils. Taken together, neutrophils greatly affect gallbladder ICLCs and dysmotility during acute cholecystitis.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review.

BACKGROUND Cystic artery pseudoaneurysm is rare, and some cases are associated with inflammation of the gallbladder. There is limited information regarding this condition, and the clinical features remain unclear. This report is a case of ruptured cystic artery pseudoaneurysm diagnosed by computed tomography (CT) imaging and treated with urgent cholecystectomy and is supported by a literature review of previous cases. CASE REPORT A 90-year-old man, who had developed acute cholecystitis due to a gallstone one month previously, was referred to our hospital. He developed fever and epigastric pain while waiting for a scheduled elective cholecystectomy. Laboratory investigations showed elevated markers of inflammation and elevated hepatobiliary enzyme levels. Computed tomography (CT) imaging showed cholecystitis and pseudoaneurysm of the cystic artery. The pseudoaneurysm had ruptured and was accompanied by the formation of a hematoma within the gallbladder that involved the liver bed. Having made the preoperative diagnosis, an urgent open laparotomy was performed, during which the gallbladder was found to have perforated. The hematoma penetrated into the liver bed. Cholecystectomy was performed, and the pseudoaneurysm of the cystic artery was extirpated. There were no serious postoperative complications. A literature review identified 50 previously reported case of cystic artery pseudoaneurysm. CONCLUSIONS A case of ruptured cystic artery pseudoaneurysm, successfully treated with urgent cholecystectomy is reported, supported by a literature review of previous cases and characterization of the clinical features of this rare condition.

Outcome of acute perforated cholecystitis: a register study of over 5000 cases from a quality control database in Germany.

BACKGROUND: Acute perforated cholecystitis (APC) is probably the most severe complication of acute cholecystitis. However, data on the outcome of cholecystectomy for APC are limited to small series. This study investigated the outcomes of cholecystectomy for APC. METHODS: Data from a prospectively maintained quality control database in Germany were analyzed. Cases with APC were compared to cases without gallbladder perforation with regard to demographic characteristics, clinical findings and surgical outcomes. RESULTS: A total of 5704 patients with APC were compared to 39,661 patients without perforation. Risk factors for APC included: the male gender, advanced age (>65 years), ASA score >2, elevated white blood count (WBC), positive findings on abdominal ultrasound sonography and fever. The APC group differed significantly from the control group with regard to fever (29.8 vs. 12.2 %), elevated WBC (83.8 vs. 65.4 %) and positive findings from ultrasound sonography (84.9 vs. 78.9 %), p < 0001. Preoperative computed tomography (CT) was ordered significantly more often in the APC group compared to the control group (2.3 vs. 1.0 %, p = 0.001). Surgery lasted significantly longer in the APC group (92.3 ± 40.8 vs. 73.7 ± 34.1, p < 0.001). The rates of conversion (18.9 vs. 6.8 %), bile duct injury (1.4 vs. 0.5 %), re-intervention (6.9 vs. 2.9 %) and mortality (4.3 vs. 1.3 %) were significantly higher in the APC group (p < 0.001). Similarly, the length of stay (13.4 ± 11.4 vs. 9.0 ± 8.3, p < 0.001) was significantly longer in the APC group. CONCLUSION: Acute perforated cholecystitis is a severe complication of acute cholecystitis. Surgical dissection could be challenging with high risks of bile duct injury and conversion. The rates of morbidity and mortality are higher compared to those of patients without perforation.

[Etiology of "difficult" laparoscopic cholecystectomy].

AIM: To define causes of difficult situations in various forms of acute cholecystitis depending on terms of disease and clinico-morphological changes in gall bladder area and to justify differentiated application of laparoscopic surgery for acute cholecystitis. MATERIAL AND METHODS: It was reviewed 1132 medical records of patients with acute cholecystitis. It is found that morphological changes in gall bladder and surrounding tissues depend on duration of follow-up of patients with acute cholecystitis and type of inflammation. RESULTS: In acute catarrhal cholecystitis "complicated" intraoperative situations are observed in 37.5% due to "loose" tissues infiltration, in phlegmonous and gangrenous forms of inflammation - in 44.6% and 63.6% respectively due to "dense" infiltrates development. CONCLUSION: Technical variants of laparoscopic cholecystectomy for various "difficult" intraoperative situations are suggested.

[Application of principles of "fast track" surgery in treatment of calculous cholecystitis].

The "fast track" concept in surgery provides rapid rehabilitation of postoperative patients, using the operative trauma reduction, adequate anesthesia--for reduction of the organism stress answer on surgical intervention. Results of treatment were analyzed in 118 patients, in whom for calculous cholecystitis the one-port transumbilical laparoscopic cholecystectomy (OPTLCH) was performed. Duration of the patients stationary treatment without abdominal cavity drainage have constituted at average (1.49 ± 0.05) days, after drainage--2.22 days. Intensity of the pain impulsation, which was determined in accordance to concentration of proinflammatory cytokins, including interleukin-1 (IL-1) and a tumor necrosis factor-α (TNF-α) after standard laparoscopic cholecystectomy (LCH) was in 1.2 times higher, than after OPTLCH. In subjective estimation of the pain intensity in accordance to visual analogous scale in patients after OPTLCH have constituted (3.42 ± 0.16) cm, and after a standard one--(5.98 ± 0.19) cm (p < 0.05).

Gallbladder motility disorders estimated by non-invasive methods.

BACKGROUND/AIMS: The aim is to compare the radionuclide (DC) and ultrasonographic (US) method in the assessment of gallbladder (GB) motility. METHODOLOGY: The study was performed in 15 controls (C), 10 patients with acute cholecystitis (AC), 20 patients with chronic acalculous cholecystitis (CAC), 26 patients with chronic cholecystitis with calculosis (CCC) as well as in 15 patients with GB dyskinesia (D). GB emptying period (EP), ejection fraction (EF) and ejection rate (ER) were estimated with dynamic cholescintigraphy (DC) and US. RESULTS: The DC and US finding in the patients with AC was typical in all the patients, i.e. GB was not visualized at all on DC, while on US, stone was visible in the cystic duct. There were significant differences (p<0.05) between the EF and ER values obtained between C and the three groups of patients CAC, CCC and D, using both methods. However, there were no significant differences in EF, EP and ER values among CAC, CCC and D (p>0.05). There was also high correlation between the results obtained with both methods in all the groups of patients studied. CONCLUSIONS: The results obtained by both methods are valuable for the assessment of GB motility. Although there are no significant differences and there is a high correlation between the values, radionuclide method is more precise, because it can register motility continuously.

[Improvement of endoscopic treatment of the acute cholecystitis].

Treatment results of 763 patients with acute cholecystitis were analyzed. Destructive forms of the disease was diagnosed by the ultrasound examination in all cases. Choledocholithiasis was diagnosed in 35 (4.6%), choledocholithiasis with papilla Vatery stricture was in 9 (1.2%) patients and isolated papilla Vatery stricture was registered in 5 (0.7%) patients. All patients were attempted to treat laparoscopically with the use of original "Device for antegrade papillotomy" and "Method of antegrade bipolar papillosphincterotomy". Authors state, that a final decision about the possibility of endoscopic treatment of the acute cholecystitis can be made after detection of anatomical structures of the Calo triangle. By complicated forms of the disease a one-stage laparoscopic treatment should be preferred. Endoscopic papillosphincterotomy should be performed only by the enblocked concrement of the papilla Vatery.

Systemic immune response after open versus laparoscopic cholecystectomy in acute cholecystitis: a prospective randomized study.

OBJECTIVE: Laparoscopic surgery is thought to reduce the postoperative immunologic effects of surgical trauma. The aim of this study is to evaluate the influence of surgical trauma on systemic inflammation and the immune response in acute cholecystitis. MATERIAL AND METHODS: Thirty-three patients with acute calculous cholecystitis were assigned to laparoscopic cholecystectomy (LC, n=18) or open cholecystectomy (OC, n=15). Blood samples were obtained preoperatively and on postoperative day 1 (24 h after surgery) and day 3 (72 h after surgery), and blood concentration of C-reactive protein (CRP), leukocyte subpopulations, as well as levels of tumor necrosis factor-alpha (TNF-alpha) ex vivo secretion by peripheral blood mononuclear cells (PBMCs) were measured in both groups. RESULTS: Hospitalization was significantly shorter in the LC group than in the OC group (LC group: 3.7+/-1.2 days versus OC group: 6.3+/-2.7 days, p=0.010). There was no postoperative morbidity in the LC group, but two patients in the OC group had postoperative complications. Postoperative TNF-alpha ex vivo secretion by PBMCs and PBMC counts in the OC group were significantly lower than those in the LC group (p=0.002). The CRP level declined by postoperative day 3, but was significantly less in the OC group than in the LC group (p<0.001). Postoperative monocyte counts significantly decreased in the OC group compared with those in the LC group (p=0.001). CONCLUSIONS: A laparoscopic approach appears to cause less surgical trauma and immunosuppression than open surgery in patients with acute cholecystitis.

Acute cholecystitis complicating cardiac surgery: case series involving more than 16,000 patients.

BACKGROUND: Acute cholecystitis after cardiac surgery is rare but carries a high mortality. Its management remains controversial. METHODS: We reviewed all cases of calculous cholecystitis (CC) and acalculous cholecystitis (ACC) encountered at our institution over the past 11 years. Data collection included preoperative variables, details of performed procedures, postoperative course, and outcome. RESULTS: The overall incidence was 0.03% for CC and 0.08% for ACC (5 and 13 of 16,576 patients, respectively). Patients in the ACC group appeared to be sicker patients whereas most patients in the CC group had an uncomplicated recovery from cardiac surgery. The diagnosis was straightforward with typical presentation and ultrasonographic findings in the CC group. In the ACC group, the presentation was less specific, and although useful as diagnostic tool, ultrasonography findings were not as consistent as in the CC group. In the CC group, 3 patients underwent surgery, and 2 patients were treated conservatively. One patient died of cardiac causes after uncomplicated cholecystectomy. In the ACC group, 7 patients were treated medically and 6 patients underwent surgery. The overall mortality was 23% (3 patients). All deaths occurred in patients treated surgically. CONCLUSIONS: Given the low incidence of CC, we do not recommend preoperative screening or intervention for cholelithiasis. Treatment should be according to established guidelines. Patients with ACC, without overt peritonitis, should initially be treated conservatively with appropriate antibiotics. However, failure of significant improvement within 48 hours or a worsening clinical picture should lead to surgical intervention.

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.

This article discusses the definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis. Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and gallbladder. Acute cholecystitis also has other causes, such as ischemia; chemicals that enter biliary secretions; motility disorders associated with drugs; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition. Factors associated with the onset of cholelithiasis include obesity, age, and drugs such as oral contraceptives. The reported mortality of less than 10% for acute cholecystitis gives an impression that it is not a fatal disease, except for the elderly and/or patients with acalculous disease. However, there are reports of high mortality for cholangitis, although the mortality differs greatly depending on the year of the report and the severity of the disease. Even reports published in and after the 1980s indicate high mortality, ranging from 10% to 30% in the patients, with multiorgan failure as a major cause of death. Because many of the reports on acute cholecystitis and cholangitis use different standards, comparisons are difficult. Variations in treatment and risk factors influencing the mortality rates indicate the necessity for standardized diagnostic, treatment, and severity assessment criteria.

Increased gallbladder trypsin in acute cholecystitis indicates functional disorder in the sphincter of oddi and could make EPT a logical procedure.

Clinical and surgical observations confirm that acute cholecystitis (ACh) and acute biliary pancreatitis can coexist and that differentiation may be difficult even at surgery. Synchronous appearance of ACh and acute biliary pancreatitis suggests a similar etiology. Endoscopic sphincterotomy, with relief of the common channel outlet obstruction, has become the established therapeutical modality that improves the outcome in acute biliary pancreatitis. Patients suffering from ACh could be treated in a similar manner to prevent reflux of pancreatic juice into the common bile duct and the gallbladder with the intention to improve the clinical course. The present study investigated the presence and amount of pancreatic trypsin in the gallbladder bile in 73 patients operated on for gallstone disease with ACh and in controls. The average gallbladder bile trypsin level in the "edematous cholecystitis" group ranged between 0.525 and 4500 ng/mL, significantly exceeding that of controls, 0.5-53 ng/mL (P < 0.0001). The average gallbladder bile trypsin level in the "gangrenous cholecystitis" group, 0.1-71.5 ng/mL, was within the range of controls (n.s.), most likely to be explained as a consequence of consumption of trypsin due to the fulminant development of the disease. Further controlled studies are mandatory before it would be acceptable to recommend endoscopic sphincterotomy as a valuable choice in the initial/early management of patients suffering from ACh. Such a study is underway to assess the possible role of obstruction at, or other disorders of, the sphincter of Oddi with consequent pancreatic juice reflux into the gallbladder as a possible initial cause of ACh.